Provider Demographics
NPI:1518192772
Name:GRAHAM, VIRGINIA (PHD, ATR-BC)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHD, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 OCEAN SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-5449
Mailing Address - Country:US
Mailing Address - Phone:386-672-8492
Mailing Address - Fax:
Practice Address - Street 1:430 BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4616
Practice Address - Country:US
Practice Address - Phone:386-258-1618
Practice Address - Fax:386-253-4215
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL221700000X221700000X
FLVG14981221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist